MEDICARE: CORY SPICER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	R74548	AZ
2	2085R0202X	Diagnostic Radiology Physician	R74548	AZ
3	2085R0202X	Diagnostic Radiology Physician	MED-PHYS-LIC-80820	MT
4	2085R0202X	Diagnostic Radiology Physician	12620A	WY
5	2085R0202X	Diagnostic Radiology Physician	M-15070	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932512811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORY SPICER M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2671
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83403-2671
Country	:	US
Telephone Number	:	208-552-8761
Fax Number	:

Provider Business Practice Location Address
First Line	:	2265 E SUNNYSIDE RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-7598
Country	:	US
Telephone Number	:	208-542-5000
Fax Number	:	208-542-5151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	05/06/2020

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Directions to “ CORY SPICER M.D.” Practice Location

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